That Whole Chain Of Survival Thing

We were dispatched early in the shift to a call that was as far from our station as can be and still be within Sorta Big City. The first due ALS unit was tied up at a long term care facility fixing the staff’s monumental airway screw up, so we were next up. By our standards, it was a long response, something like 11 minutes. Fortunately for the patient there is a fire station around the corner and even more fortunately one of our BLS units had just left there after getting fuel and was only a couple of minutes behind the first responders.

The fire department arrived to find the patient in cardiac arrest and the family and friends were agitated and hostile. I should mention that this was in a bar and grill, with the emphasis on bar. The fire department called for the police to come right away. Somehow, the managed to hold off the bystanders AND do CPR until the police and BLS unit arrived. Meanwhile we were riding to the rescue. Or something.

By the time we actually arrived, the fire and BLS crew were loading the patient into the BLS ambulance. We got a report as follows,

“He went into the bathroom and when he didn’t return after 15 or so minutes his son went in and found him unconscious. The FD found him in arrest, but someone had moved him from the bathroom. We shocked him twice and continued CPR until you got here. He has a cardiac history and was seen by cardiology at Sort Of Big City Medical Center, who decided he didn’t need the cath lab.”

All of this given in one long sentence while we were loading the patient and our lifesaving equipment into the ambulance and doing CPR.

My partner got to the head of the patient and continued ventilation as I turned on the monitor and connected the defib pads to the cable. Someone was doing CPR, another EMT grabbed the IV stuff out of our bag and set up the line, I grabbed the airway kit and handed it to my partner. All in about 30 seconds.

Then my partner said, “Hey, he’s making respiratory efforts.” Which got our attention. I looked at the screen of the monitor and saw this.

Before that even registered on my brain I hit the Analyze button and saw this,

“Got a nice rhythm here, check for pulses.’

“Got a nice carotid, someone try to grab a pressure.”

While that was going on my partner was setting up to intubate, someone was ventilating the patient, I was putting on the leads, and someone was talking to the now calmer family.

“180 over 90.” Nice

I sent one of the EMTs over to our unit to get the chilled saline because this was a prime candidate for therapeutic hypothermia. In the mean time, my partner intubated the patient, I started two IVs, my partner mixed Amiodarone, someone ventilated the patient, and the chilled saline arrived. Everyone was moving, everyone was doing something, no one stood there with their thumbs up their ass. Oh yeah, I managed to hit Print and got a nice strip.

Then I changed the view selection to get this,

Good tube, good O2 sat, good rhythm. And a blood pressure as a bonus. We started the Amiodarone infusion in one arm and chilled saline in the other. Ice packs to the recommended areas. The only bad thing was that there was no reaction from the patient other than his respiratory efforts. Which was an encouraging sign, but still.

Time to start moving to the hospital. Since Sorta Big City Medical Center was further than World Famous Medical Center, we decided to go to WFMC. Besides, WFMC was going to have to do SBCMC’s warranty work since they had passed on the cath lab thing for the patient. Ooops.

One last thing while to do, the obligatory 12 Lead ECG.

Yeah, probably should have done that cath lab thing.

The rest of the call was pretty routine as cardiac arrest saves go. Continue cold saline, continue to monitor vital signs, do a couple more 12 Lead ECGs (which weren’t any better looking), and of course call the hospital.

We arrived at the hospital and went right into their critical care area. The cath lab doctor showed up a few minutes later and a few minutes later they were prepping the patient for the cath lab.

Oh, did I mention that patient started moving his arms just as we arrived at the hospital? I took that as a very good sign. He got promptly sedated when we rolled into the resuscitation room, but he was still trying to move.

Of course, I’ll never find out if he survived, because we rarely get follow up.

A couple of take home points here.

First, more non EMS people need to know CPR, especially if they have loved ones who might need it.

Second, attacking the people coming to help your loved ones is just stupid. I won’t even accept any “cultural differences” excuses for that one.

Third, the most important tools in getting return of spontaneous circulation (ROSC) are good CPR and electricity. This patient got both despite his family and friends.

Fourth, ROSC is not enough. Which is where the ALS part comes in. Controlling the patient’s airway after ROSC is important because if he vomits and aspirates the vomit, he’s likely to die form Aspiration Pneumonia. Giving the drugs may or maybe won’t help. Chilling the patient has proven benefit, although there is some question of how soon to begin it. As with cath labs, the sooner the better seems to be the answer.

Fifth, although I made for of SBCMC and their cardiology department, sending this patient to the cath lab or not is the sort of judgement call that has to be made every day in hospitals.

Six, this is the type of call that good paramedics dream of. A very sick patient, everything went right, knowledge and skills were used, and the patient benefited. It really just doesn’t get much better.

Comments

Feels good when everyone knows what to do and does it. That’s why although I like teaching new folks, I often miss working with experienced partners… that flow is one of the real pleasures of this job.

(By the way, I think a couple images might have gotten mixed; the first two strips there are identical.)

We are and would have but the thermometer is a separate piece of gear and we just forgot to bring it over from our unit. The protocol says “when possible” taking into account things like that and my experience is that we don’t really drop temperatures that much during our transports. The real benefit is that we start it and prompt the hospitals to continue it.

Yes, no doubt. I don’t know how good your local hospitals are with it, but have you ever had them fail to take the baton with cooling in a timely manner once you’ve it’s already been initiated? (i.e. not at all, or “oh, hmm, anyone know where the arctic sun is? can somebody page cardiology?”)

They all are on board with this. When we started doing this, it was specifically the intent of our then medical director to push the hospitals to start doing this. He got them all to agree to continue cooling once we started it in the field. If they didn’t agree, they weren’t going to get post arrest patients. He was all about survival to discharge neurologically intact. He pushed the hospitals to accepting an agreement for a STEMI point of entry plan as well as this. Very cardiology centric non cardiologist.

We’ve had good experience with the hospitals and good success rates at discharge.

All About Me

After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it?
I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs.
I still write about EMS, but I'm adding more and more non EMS subject matter.
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